Transcript UNIS Template

Health classifications:
Developments and applications
Richard Madden
National Centre for Classification in Health
Outline
› Family of International Classifications (WHO-FIC)
› Australian modifications: future possibilities
› Applications, including Activity Based Funding (ABF)
› Sub-acute assessment instruments
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WHO Family of Classifications:
Reference Classifications
International Classification
of Diseases – ICD
International Classification
of Functioning, Disability
and Health – ICF
International Classification of
Interventions – ICHI
International Classification of Diseases (ICD)
ICD Revision
› ICD has existed since late 19th century
› Earlier work by Farr, Bertillon (Moriyama 2011, NCHS website)
› Designed for cause of death classification
› Morbidity as a secondary use from 1948
› ICD-10 1990
› ICD revision
- Revision process
- Foundation layer
- Versions (Linearisations)
- Coding standards
- Implications for user countries
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ICD-11 Morbidity Coding Standards
› ICD-10 version only for single condition coding
- hence the Australian Coding Standards, for multiple condition coding
› Standards have been debated by the Morbidity Reference Group (20072010) and the Morbidity TAG (2010-2012), but there is no finality
› Aim is a set of standards for multiple condition coding
› Issues include
- Post coordination (X chapter)
- Main condition
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Implications for user countries
› Field trials for Morbidity version
- to test morbidity version (against ICD-10 and national modifications)
- to analyse problematic topics
- to influence final version of ICD-11 morbidity
› Inclusion of ICD-11 material in ICD-10 and so national modifications
› Future national morbidity applications/modifications of ICD-11:
› aim should be early (2019?) adoption of ICD-11 for morbidity with
minimum modification
› WHO will require national modification material to be included in ICD-11
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International Classification of Health Interventions
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Development of ICHI
› WHO International Classification of Procedures in Medicine: 1978
› Decision not to update in late 1980s
› Multiple national classifications
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Australia
Canada
China
France
Germany
UK
US
Why develop ICHI?
› Proliferation of national classifications
› Limited scope of national classifications
› Many countries without a classification
› Enable international comparisons
ICHI Development to date
› Began 2007, by WHO-FIC Family Development Committee
› Structure, Content Model and Coding Scheme finalised 2010
› Alpha version released October 2012
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Target, Action and Means axes
Medical and surgical interventions
Public health interventions
Editorial and coding rules
› Alpha 2 version October 2013, further development for
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Functioning interventions
Mental health interventions
Nursing interventions
Primary care interventions
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Features of ICHI
› Limited granularity
- Useable as is in some countries
- Facilitate international comparisons
- Limited updating required
› Broad coverage
- Ensures counting of all types of interventions
› Base for national classifications
- Map existing classifications to ICHI (Canada, China, France use same structure)
- New national classifications
- Redevelopment of existing classifications (Australia, Germany, UK)
ICHI Organising Principle
“What is done to whom, and how”
Excludes:
Who performs the intervention
(Provider)
Why
(Diagnosis, functioning)
Where
(Setting)
Health Intervention
1. Target
2. Action
3. Means
International Classification of Functioning,
Disability and Health (ICF)
ICF biopsychosocial model
Health Condition
(disorder/disease)
Body functions &
structures
Activities
Environmental
Factors
Participation
Personal
Factors
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ICF dimensions
› Body functions
› Body structures
› Activities and participation (A & P)
› Environmental factors
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Broad description of Health: ICD and ICF together
ICD and ICF together:
› ‘provide exceptionally broad yet accurate tools to capture the full picture of
health’ (ICD-10 Second Edition)
› ‘provide a broader and more meaningful picture of the health of people or
populations’ (ICF)
› Focus on ICD alone ignores important aspects of health
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Related WHO-FIC Classifications
› ATC
(medicines)
› ICPC
(primary care)
› ICECI
(external causes)
› ICNP
(nursing practice)
› ISO 9999
(aids and appliances)
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Future Australian Classifications: ICD
› Need for Australian modification will change/diminish; will depend on
- Content of ICD morbidity version
- ICD updating: timeliness and quality
- ICD coding standards (not likely to replace ACS)
› Matter for many agencies to consider : AIHW, IHPA, NHISSC, jurisdictions
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Future Australian Classifications: ACHI
Not reviewed since development in mid 1990s:
- ACHI is based on the Medical Benefits Schedule, itself derived from the AMA’s
Most Common Fee list (pre-Medibank)
- ACHI has limited scope for expansion
- Varying granularity
- Does not cover ambulatory well
- ICHI can provide a base for a new classification
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Applications of ICD, ACHI and ICF
› Activity Based Funding
- Acute (possible inclusion of functioning)
- Sub-acute (ICF based approach discussed later)
- Ambulatory
› Patient safety
› Health system
- Quality
- Planning
› Public health
- Aggregation (vaccination coverage, infectious, chronic disease management)
- Visibility
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Sub-acute assessment instruments review
› University of Sydney, August 2012-March 2013
› Followed 2011 PwC initial review and analysis
› Wide consultation across Australia
› Adopted ICF as the benchmark for assessment review
› Reviewed a wide range of assessment instruments
› Issues for specific groups: children, rural/remote, Indigenous
› ‘Need for assistance’ is the assessment construct, not ‘difficulty’
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Sub-acute classification: rehabilitation
› AN-SNAP, reliant on FIM assessment
› Opinions on the FIM varied:
- Assesses need for assistance
- Inpatients: FIM domains adequate (including Faculty view); others considered
that the domains were not sufficient for complex rehabilitation care
- Non-admitted: Broad agreement on the need for expansion of domain range
- Critical comments were made on ceiling effects and the adequacy of the
cognition domains
- The training program was seen as a strength and also a burden (formality)
- Strong view that the large investment in the FIM and related systems should not
be discarded lightly
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Rehabilitation Option 1: medium term
Option 1(medium term): a combination of instruments
FIM would be retained
A second instrument would be added, to assess need for assistance
in relation to the range of ICF A&P domains not covered by the FIM
The Assessment of Living Skills and Resources (ALSAR) is
proposed as the additional instrument
Clinician could have the option of not using the ALSAR, with the
minimum ALSAR score being assigned
An additional instrument, the Rowland Universal Dementia
Assessment Scale (RUDAS), could be included to improve assessment of
cognition
Alternative version for children: weeFIM + CASP
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Rehabilitation Option 2: longer term
Option 2 (longer term): development of a new instrument, AusRehab
Designed to measure need for assistance
AusRehab consists of 18 items covering the full range of ICF A&P
domains
Six of the 18 domains can be mapped directly from the FIM items,
meaning that FIM users would need to assess 12 additional domains
Broad groups of Activities and Participation domains:
Learning, management and communication
Mobility
Self-care
Getting along with people
Performance in major areas of life
Community participation
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Rehabilitation Option 2 (continued)
› AusRehab would apply to inpatients and non-admitted patients
› Impact of behaviours of concern on costs: possible extra item
› Suggested 5 point scale
› Close alignment of AusRehab domains with Occup. Therapy AusTOMs
› 15 domain version for children, AusRehabChild (includes Play)
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Geriatric Evaluation and Management (GEM)
Substantial inconsistency in use of the GEM care type across Australia:
68% of Australian GEM public hospital separations were in Victoria in 2010-11
The importance of co-morbidities in GEM patients
Option 1: FIM + ALSAR, possibly also RUDAS
Option 2: New instrument AusGEM
17 items across full range of ICF A&P domains
In-patients and non-admitted patients
Co-morbidities: test a small range for cost explanatory impact
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Palliative care
› General satisfaction with uses of phases of care
› Four instruments in use (PCOC instruments)
› Limited use of psycho-social factors
› Longer term proposal to develop a new instrument:
- AusPallCare 6 domains (incorporating the 4 RUG-ADL domains)
Changing and maintaining body position
Transferring ones' self
Toileting
Eating
Interpersonal interactions and relationships
Community, social and civic life
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Palliative care (continued)
› AIHW found that 45% of patients coded as receiving palliative care are not
palliative care type.
- AusPallCare should be applied to all patients receiving palliative care
› Instrument for children needs more consideration, noting many patients
are acute care type (strong interest from Australian and New Zealand
Paediatric Palliative Care Reference Group)
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Other care types
› Psychogeriatric
- Included in the considerations of the IHPA Mental Health Working Group, and
decisions on assessment should be made in light of the recommendations of that
Group
- Possible 7 domain instrument described (ICF based, include RUG-ADL domains)
› Maintenance
- Continue with RUG-ADL
- Issue of recording barriers to discharge (ICD codes)
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Thank you
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